Sentinel Lymph Node Technique Research Articles

Application of Sentinel Lymph Node Technique to Transvaginal Natural Orifices Transluminal Endoscopic Surgery in Endometrial Cancer

Study ObjectiveThis report outlines our first experience of sentinel lymph node (SLN) mapping in the natural orifices transluminal endoscopic surgery (NOTES) technique, which is the combination of the least invasive surgical approach and the least invasive way of assessing lymph node status. DesignDescriptive study (Canadian Task Force classification III). SettingTertiary referral and educational center. PatientsFour patients with endometrial cancer clinical stage 1. InterventionsNOTES with SLN mapping using an indocyanine green–based near-infrared fluorescence imaging technique. Measurements and Main ResultsThe average operative time was 182.75 minutes (standard deviation, 34.5). Mean estimated blood loss was 67.5 mL (standard deviation, 39.4). All patients had surgical staging of International Federation of Gynecology and Obstetrics stage IA (pT1aN0). The overall detection rate and bilateral detection rate were 100% (4/4). All procedures were successfully completed without complication or conversion to conventional laparoscopy. ConclusionIn our preliminary experience, SLN mapping in NOTES surgery appears to be feasible and safe. It can be considered as an alternative method to reduce morbidity from radical lymphadenectomy and provide the benefits from the NOTES technique. However, studies in a larger population are necessary.

Life-threatening isosulfan blue induced anaphylaxis during laparoscopic hysterectomy

The use of blue dye alone is the first described technique for sentinel lymph node (SLN) identification in patients with cervical carcinoma. In this procedure, Isosulfan Blue (IB), Methylene Blue or Patent Blue is injected into each quadrant of the cervix. We present an anaphylactic reaction to IB in a patient who underwent a laparoscopic hysterectomy. Approximately 15 min after the dye injection, the patient developed hypotension (55/35 mmHg) with an increase in heart rate (120 beats/minute) and a decrease of pulse oximetry to 85%. She was treated successfully with ephedrine, adrenaline, and fluid administration. When sterile drapes were removed, blue urticarial rashes all over the body were detected. The operation was halted, and the patient was transferred to the intensive care unit (ICU). Almost 4 hours after injection of IB, she experienced a second attack of bronchospasm under mechanical ventilation. She recovered uneventfully and was discharged from the ICU. The patient was referred to a skin prick test which was positive for IB. SLN biopsy for cervical cancers may have an increased risk of anaphylaxis probability due to administered blue dyes. It is crucial that the medical staff involved in these procedures be aware of anaphylactic reactions. This case report highlights the necessity of close monitoring of these patients in both the intraoperative and postoperative periods.

Selective sentinel lymph node biopsy in male breast cancer

ObjectiveTo evaluate the reproducibility of the sentinel lymph node (SLN) technique in male breast cancer. Material and methodsWe retrospectively analyzed 21 male patients diagnosed with breast cancer in our hospital from 2008 to 2016 with, at least, 18 months follow-up. Fifteen patients underwent selective sentinel lymph node biopsy (SLNB) following the usual protocols with peritumoral injection of 18.5–111MBq of 99mTc-nanocoloides and acquisition of planar images 2h after the injection. In 2 cases it was necessary to perform a SPECT/CT to locate the SLN. Immunohistochemistry and molecular techniques (OSNA) were used for their analysis. Six patients did not undergo SLNB because they had pathological nodes or distant disease at the time of diagnosis. ResultsSLNB was performed in 15 patients. The SLN was negative in 6 patients and positive in the remaining 9. Three patients with positive SLNB did not need axillary lymphadenectomy because of the low number of copies by molecular analysis OSNA. Axillary lymphadenectomy was performed in the remaining 6 patients with the result of 4 positive axillary lymphadenectomies and 2 that did not show further extension of the disease. ConclusionsAccording to our experience, SLNB in males is a reproducible, useful, safe and reliable technique which avoids unnecessary axillary lymphadenectomy and prevents the appearance of undesirable effects.

What about sentinel lymph node biopsy for early breast cancer during pregnancy?

Pregnancy-associated breast cancer is rare, but this clinical situation arises in 1/10,000–1/3000 pregnancies. In patients presenting an early-stage breast tumor devoid of clinically pathological lymph node, sentinel lymph node (SLN) biopsy has not yet been validated as a routine procedure for pregnant women due to the lack of data in the literature. The blue dye injection is not recommended because of 2% theoretical risk of anaphylactic shock. Several studies have shown that Tc99m injection at conventional dose between 12.1 and 18.5MBq exposed the fetus to an irradiation between 0.011 and 0.0245mSv much below the 50mSv recommended threshold. As evidenced by lymphoscintigraphy scans, the dose of injected Tc99m is localized at the injection site and in the SLN. According to the literature, the SLN technique does not seem to impact the fetal or obstetrical prognosis. Studies involving larger cohorts are required to confirm these data and to indicate this technique in pregnant women. Considering the benefit for the patient and the low risk incurred on both fetal and obstetrical levels, it appears reasonable to discuss the indication of SLN on a case-by-case basis in multidisciplinary oncologic meetings.

Sentinel Node in Cutaneous Squamous Cell Carcinoma of the Trunk and Extremities: Experience in a Latin American Reference Center

This paper aims to assess the use of the sentinel node technique in squamous cell carcinoma (SCC) of the trunk and extremities in a Latin American oncology reference center. The descriptive retrospective cohort study included 60 patients diagnosed with SCC of the trunk and extremities, submitted to surgical treatment of the primary tumor and sentinel node biopsy at the breast and soft tissue tumor services of the National Institute of Cancerology (Bogotá, Colombia) over a period of 6 years. The sentinel node was identified in 96.6% (58/60) of the patients. The sentinel node pathology report was negative in 81.7% (49), positive in 15% (9). There were no complications due to the procedure in 85% of the patients. The mean recurrence-free survival time was 8.3 months (CI 95% 5.0 to 11.5 months) in patients with positive sentinel node and 58.6 months (CI 95% 47.8 to 69.3 months) in patients with negative results. Only 4 of 49 patients (8.1%) with negative sentinel node had regional relapse. The study evidenced that the sentinel node technique in patients with high-risk SCC of the trunk and extremities is an adequate staging tool for the lymph node chain, with a low rate of associated complications. This opens an interesting opportunity for prospective cohort studies that can demonstrate statistically significant differences.

Secondary Node Analysis as an Indicator for Axillary Lymphadenectomy in Breast Cancer Patients

IntroductionCurrently, there is no agreement regarding if it would be necessary to perform an axillary lymph node dissection (ALND) in patients who have macrometastases in the sentinel lymph node (SLN). We studied the utility of the secondary node analysis (SN), defined as the following node after the SLN in an anatomical and lymphatic pathway, as a sign of malignant axillary involvement. MethodsAn observational, retrospective and multicenter study was designed to assess the utility of the SN as a sign of axillary involvement. Among 2273 patients with breast cancer, a valid sample of 283 was obtained representing those who had the SN studied. Main endpoints of our study were: the SLN, the SN and the ALND histological pattern. Sensitivity, specificity and precision of the test were also calculated. ResultsSN test, in cases with positive SLN, has a sensitivity of 61.1%, a specificity of 78.7%, a positive predictive value of 45.8% and a negative predictive value of 87.3% with a precision of 74.7%. ConclusionThe study of the SN together with the technique of the SLN allows a more precise staging of the axillary involvement, in patients with breast cancer, than just the SLN technique.

Ganglio secundario como indicador de linfadenectomía axilar en pacientes afectas de cáncer de mama

IntroductionCurrently, there is no agreement regarding if it would be necessary to perform an axillary lymph node dissection (ALND) in patients who have macrometastases in the sentinel lymph node (SLN). We studied the utility of the secondary node analysis (SN), defined as the following node after the SLN in an anatomical and lymphatic pathway, as a sign of malignant axillary involvement. MethodsAn observational, retrospective and multicentre study was designed to assess the utility of the SN as a sign of axillary involvement. Among 2273 patients with breast cancer, a valid sample of 283 was obtained representing those who had the SN studied. Main endpoints of our study were: the SLN, the SN and the ALND histological pattern. Sensitivity, specificity and precision of the test were also calculated. ResultsSN test, in cases with positive SLN, has a sensitivity of 61.1%, a specificity of 78.7%, a positive predictive value of 45.8% and a negative predictive value of 87.3% with a precision of 74.7%. ConclusionThe study of the SN together with the technique of the SLN allows a more precise staging of the axillary involvement, in patients with breast cancer, than just the SLN technique.

Subserosal uterine injection of blue dye for the identification of the sentinel node in patients with endometrial cancer: a feasibility study.

To define the detection rate, sensitivity, and negative predictive value (NPV) of the sentinel node technique in patients with endometrial cancer. Patients with endometrial cancer after informed consent underwent subserosal injection of blue dye during hysterectomy in a tertiary gynae/oncology department between 2010 and 2014. The procedure was performed in all cases by the same team including two gynae/oncologist consultants and one trainee. All relevant perioperative clinicopathological characteristics of the population were recorded prospectively. The identified sentinel nodes were removed separately and a completion bilateral pelvic lymphadenectomy followed in all cases. Simple statistics were used to calculate the sensitivity and NPV of the method on per patient basis. Fifty-four patients were included in this study. At least one sentinel node was mapped in 46 patients yielding a detection rate of 85.2%. Bilateral detection of sentinel nodes was accomplished in only 31 patients (57.4%). The mean number of sentinel nodes was 2.6 per patient and the commonest site of identification was the external iliac artery and vein area (66%). Six patients (11%) had a positive lymph node, and in five of them, this was the sentinel one yielding a sensitivity of 83.3% and an NPV of 97.5%. The overall detection rate improved significantly after the first 15 cases; however, this was not the case for the bilateral detection rate. Our study is in accordance with previous studies of sentinel node in endometrial cancer and further demonstrates and enhances the confidence in the technique. In the current era of an ongoing debate on whether a systematic lymphadenectomy in patients with endometrial cancer is still necessary, we believe that the sentinel node is an acceptable alternative and should be applied routinely in tertiary centres following a strict algorithm.

Optimal duration of adjuvant chemotherapy for high-risk node-negative (N–) breast cancer patients: 6-year results of the prospective randomised multicentre phase III UNICANCER-PACS 05 trial (UCBG-0106)

PurposeOptimal duration of adjuvant chemotherapy in the treatment of early-stage breast cancer remained to be investigated rigorously for the standard regimens in widespread use in North America (doxorubicin/cyclophosphamide, AC) and Europe (5-fluorouracil/epirubicin/cyclophosphamide, FEC). Whether six cycles of FEC 100 present an advantage, or not, compared with only four cycles was tested directly in a phase III prospective multicentre trial. Patients and methodsBetween 2002 and 2006, 1515 women between 18 and 65°years of age, with node negative N(−) high-risk early-stage breast cancer, were included in the study following breast surgery and axillary lymph node dissection or procedure by sentinel node technique. Inclusion in the study required tumour size T ≥ 1 cm and at least one of the high-risk factors: T > 2 cm, negative oestrogen receptor/progesterone receptor (ER– and PR–), Scarff-Bloom-Richardson (SBR) grade II or III and age ≤ 35°years. Patients were randomly assigned to either six FEC 100 (Arm A) or four FEC 100 (Arm B). The trial was powered to detect an absolute difference ≥6% in disease-free survival (DFS) at 5°years. ResultsAt 6.1°years median follow-up, with 91 (12%) events recorded in Arm A versus 106 (14%) in Arm B, no statistically significant risk increase was associated with four versus six FEC 100: DFS (hazard ratio (HR) = 1.18; CI 95% [0.89–1.56], P = .24) and overall survival (OS) (HR = 1.39; CI 95% [0.91–2.13], P = .12). ConclusionDifferences in chemotherapy duration did not induce notably different outcomes in our cohort of high-risk patients. Clinical trial registry numberNCT00055679, Agence National de Sécurité du Médicament (ANSM) – France.

What is new in pediatric surgical oncology?

As pediatric oncology has become more complex, designing and maintaining pediatric surgical protocols require greater expertise. The primary purpose of this review is to summarize the changes in protocols and new study findings, which have changed surgical practice for children with solid tumors. The most common solid tumors treated by surgery are reviewed. There are new methods of surgical techniques such as the use of sentinel lymph node techniques for the assessment of lymph nodes in pediatric sarcoma. New studies showing excellent outcomes for the nonoperative treatment for young patients with neuroblastoma are discussed. Surgical quality with the prevention of tumor rupture and the assessment of lymph nodes is essential for good outcomes in patients with Wilm's tumor. The international collaborations within germ cell and liver tumors have provided excellent new study regimens and welcomed a new era of studies that are robust and have the power to change the outcomes for these rare tumors. Surgical practice is evolving with the molecular advances in pediatric oncology. Technical advances and quality improvement endeavors to ensure protocol adherence are essential. International partnerships have allowed for greater advances particularly for rare tumors and improve overall surgical outcomes.

French updated recommendations in Stage I to III melanoma treatment and management.

As knowledge continues to develop, regular updates are necessary concerning recommendations for practice. The recommendations for the management of melanoma stages I to III were drawn up in 2005. At the request of the Société Française de Dermatologie, they have now been updated using the methodology for recommendations proposed by the Haute Autorité de Santé in France. In practice, the principal recommendations are as follows: for staging, it is recommended that the 7th edition of AJCC be used. The maximum excision margins have been reduced to 2 cm. Regarding adjuvant therapy, the place of interferon has been reduced and no validated emerging medication has yet been identified. Radiotherapy may be considered for patients in Stage III at high risk of relapse. The sentinel lymph node technique remains an option. Initial examination includes routine ultrasound as of Stage II, with other examinations being optional in stages IIC and III. A shorter strict follow-up period (3 years) is recommended for patients, but with greater emphasis on imaging.

Accuracy of detection rate and intraoperative sentinel lymph node assessment in early-stage cervical carcinoma

Objective: This article shows our experience on sentinel lymph node (SLN) biopsy in early-stage cervical carcinoma since the technique was introduced in our Institution. The main objective is to analyze the detection rate (DR) of metastatic SLNs, identifying prognostic factors for an increased risk of nodal metastases. Our second aim was to compare the accuracy of nodal metastases DR between intraoperative analysis and postoperative ultrastaging. Materials and Methods: Forty-one women with the International Federation of Gynecology and Obstetrics stages IA2-IIA1 who underwent laparoscopic surgical treatment applying the SLN technique, from December 2011 to June 2016, at La Paz University Hospital, were included. The sentinel node was identified using technetium and methylene blue dye or indocyanine green near-infrared fluorescent imaging, analyzed intraoperatively, and compared to deferred ultrastaging. Results: SLN DR was 100%, with a bilaterality rate of 83%. Twelve (26.8%) patients had metastatic nodes, 11 of them (91.7%) detected by SLN technique, of which 9 (81.8%) had only the sentinel node affected. False-negative rate was 2.4% after ultrastaging procedure. Metastatic SLN detection with ultrastaging was 45.5% higher than the intraoperative analysis, 63.6% of which had low tumor burden. The global detection of patients with nodal metastases after SLN technique was 21.9% higher than pelvic lymphadenectomy. Conclusions: Our preliminary results corroborate that SLN biopsy selectively maps metastatic nodes and ultrastaging increases the detection of metastatic SLNs, predominantly due to low tumor burden.

Sentinel node biopsy and lymphatic mapping in penile and prostate cancer.

Nodal metastases are linked to poor outcome in men with penile or prostate cancer. Early detection and resection are important for staging and for the prognosis. However, lymphadenectomy is associated with morbidity and may miss metastases when performed solely on the basis of anatomical templates. In this article we describe the technique and benefits of sentinel node biopsy (SNB) and provide a review of the literature. Dynamic sentinel node techniques using both radioactive and optical (hybrid) tracers have been proven effective in penile cancer. For prostate cancer, SNB added to extended nodal dissection may further tailor dissection to the highly variable lymphatic drainage patterns in the pelvis. The sensitivity of SNB was found to be superior to conventional imaging methods; however, false-negative SNB procedures can occur and acomplementary extensive lymphadenectomy is required to remove additional positive nodes that were not detected in the SNB template. SNB is astandard method for early detection of nodal metastases in penile cancer and provides superior diagnostic accuracy to conventional imaging modalities in prostate cancer.

Review of sentinel node procedure in cN0 head and neck squamous cell carcinomas. Guidelines from the French evaluation cooperative subgroup of GETTEC

The reliability of the sentinel lymph node (SN) technique has been established for more than ten years in T1-T2 oral cavity and oropharynx squamous cell carcinoma. Although most authors stress the necessity of rigorous implementation, there are no agreed guidelines. Moreover, other indications have been described, in other anatomical areas of the upper aerodigestive tract and in case of previous surgery or radiotherapy. SN expert teams, under the GETTEC head and neck tumor study group, conducted a review of the key points for implementation in head and neck cancers through guidelines and a review of classical and extended indications. Reliability depends on respecting key points of preoperative landmarking by lymphoscintigraphy, and intraoperative SN sampling and histological analysis. The SN technique is the best means of diagnosing occult lymph node involvement, whatever the primary tumor location, T stage or patient history.

Predictors of sentinel lymph node metastases in breast cancer-radioactivity and Ki-67

ObjectivesSince the introduction of the sentinel node technique for breast cancer in the 1990s patient's morbidity was reduced. Tracer uptake is known to be dependent from lymph node integrity and activity of macrophages.The aim of this study was to assess whether radioactivity of the tracer can predict sentinel lymph node metastases. Furthermore, a potential association with Ki-67 index was examined. Non-invasive prediction of lymph node metastases could lead to a further decrease of morbidity. MethodsWe retrospectively analyzed patients with primary breast cancer who underwent surgery at the Department of Obstetrics and Gynecology in the University Hospital of Cologne between 2012 and 2013. Injection of radioactive tracer was done a day before surgery in the department of Nuclear Medicine. Clinical data and radioactivity of the sentinel node measured the day before and intraoperatively were abstracted from patient's files. ResultsOf 246 patients, 64 patients had at least one, five patients had two and one patient had three positive sentinel lymph nodes. Occurrence of sentinel lymph node metastases was not associated with preoperative tracer activity (p = 0,319), intraoperative tracer activity of first sentinel node (p = 0,086) or with loss of tracer activity until operation (p = 0,909). There was no correlation between preoperative Ki-67 index and occurrence of lymph node metastases (p = 0,403). ConclusionIn our cohort, there was no correlation between radioactivity and sentinel node metastases. Tracer uptake might not only be influenced by lymph node metastases and does not predict metastatic lymph node involvement.

Sentinel lymph node biopsy as a prognostic factor in non-metastatic colon cancer: a prospective study.

Around a third of node-negative patients with colon cancer experience a recurrence after surgery, suggesting poor staging. Sentinel lymph node techniques combined with immunochemistry could improve colon cancer staging. We prospectively assessed the effect of Sentinel node mapping on staging and survival in patients with non-metastatic colon cancer. An observational and prospective study was designed. 105 patients with colon cancer were selected. Patients were classified according to node involvement as: N1, with node invasion detected by the conventional techniques; up-staged, with node invasion detected only by sentinel node mapping; and N0, with negative lymph node involvement by both techniques. Five-year survival and disease-free survival rates were analysed. Multivariate regression analyses were performed to identify prognostic factors for disease-free and overall survival. Sentinel node mapping was successfully applied in 78 patients: 33% were N1; 24.5% were up-staged (18 patients with isolated tumour cells and 1 patient with micrometastases); and 42.5% were N0. N1 patients had the poorest overall 5-year survival (65.4%) and 5-year disease-free survival (69.2%) rates compared with the other two groups. No significant 5-year survival differences were observed between N0 patients (87.9%) and up-staged patients (84.2%). Patients up-staged after sentinel node mapping do not have a poorer prognosis than patients without node involvement. Detection of isolated cancer cells was not a poor prognosis factor in these patients.

Actualisation des recommandations de prise en charge du mélanome stades I à III

As knowledge continues to develop, regular updates are necessary concerning recommendations for practice. The recommendations for the management of melanoma stages I to III were drawn up in 2005. At the request of the Société Française de Dermatologie, they have now been updated using the methodology for recommendations proposed by the Haute Autorité de Santé. In practice, the principal recommendations are as follows: for staging, it is recommended that the 7thedition of AJCC be used. The maximum excision margins have been reduced to 2cm. Regarding adjuvant therapy, the place of interferon has been reduced and no validated emerging medication has yet been identified. Radiotherapy may be considered for patients in stage III at high risk of relapse. The sentinel lymph node technique remains an option. Initial examination includes routine ultrasound as of stage II, with other examinations being optional in stages IIC and III. A shorter strict follow-up period (3years) is recommended for patients, but with greater emphasis on imaging.

Laparoscopic sentinel lymph node dissection in prostate cancer patients: the additional value depends on preoperative data.

In intermediate- or high-risk prostate cancer (PC) patients, to avoid extended pelvic lymph node dissection (ePLND), the updated Briganti nomogram is recommended with the cost of missing 1.5% of patients with lymph node invasion (LNI). Is it possible to reduce the percentage of unexpected LNI patients (nomogram false negative)? We used the isotopic sentinel lymph node (SLN) technique systematically associated with laparoscopic ePLND to assess the potential value of isotopic SLN method to adress this point. Two hundred and two consecutive patients had procedures with isotopic SLN detection associated with laparoscopic ePLND for high or intermediate risk of PC. The area under the curve (AUC) of the receiver operating characteristics (ROC) analysis was used to quantify the accuracy of different models as: the updated Briganti nomogram, the percentage of positive cores, and an equation of the best predictors of LNI. We tested the model cutoffs associated with an optimal negative predictive value (NPV) and the best cutoff associated with avoiding false negative SLN detection, in order to assist the clinician's decision of when to spare ePLND. LNI was detected in 35 patients (17.2%). Based on preoperative primary Gleason grade and percentage of positive cores, a bivariate model was built to calculate a combined score reflecting the risk of LNI. For the Briganti nomogram, the 5% probability cutoff avoided ePLND in 53% (108/202) of patients, missing three LNI patients (8.6%), but all were detected by the SLN technique. For our bivariate model, the best cutoff was <10, leaving no patient with LNI due to positive SLN detection (four patients = 11.4%), and avoiding ePLND in 52% (105/202) of patients. For patients with a low risk of LNI determined using the updated Briganti nomogram or bivariate model, SLN technique could be used alone for lymph node staging in intermediate- or high-risk PC patients.

A Specific Mapping Study Using Fluorescence Sentinel Lymph Node Detection in Patients with Intermediate- and High-risk Prostate Cancer Undergoing Extended Pelvic Lymph Node Dissection

Sentinel lymph node (SLN) detection techniques have the potential to change the standard of surgical care for patients with prostate cancer. We performed a lymphatic mapping study and determined the value of fluorescence SLN detection with indocyanine green (ICG) for the detection of lymph node metastases in intermediate- and high-risk patients undergoing radical prostatectomy and extended pelvic lymph node dissection. A total of 42 patients received systematic or specific ICG injections into the prostate base, the midportion, the apex, the left lobe, or the right lobe. We found (1) that external and internal iliac regions encompass the majority of SLNs, (2) that common iliac regions contain up to 22% of all SLNs, (3) that a prostatic lobe can drain into the contralateral group of pelvic lymph nodes, and (4) that the fossa of Marcille also receives significant drainage. Among the 12 patients who received systematic ICG injections, 5 (42%) had a total of 29 lymph node metastases. Of these, 16 nodes were ICG positive, yielding 55% sensitivity. The complex drainage pattern of the prostate and the low sensitivity of ICG for the detection of lymph node metastases reported in our study highlight the difficulties related to the implementation of SNL techniques in prostate cancer. Patient summaryThere is controversy about how extensive lymph node dissection (LND) should be during prostatectomy. We investigated the lymphatic drainage of the prostate and whether sentinel node fluorescence techniques would be useful to detect node metastases. We found that the drainage pattern is complex and that the sentinel node technique is not able to replace extended pelvic LND.

Internal Mammary Nodes in Breast Cancer: A Review of the Literature and Practical Surgical Recommendations

Background : Involvement of internal mammary lymph nodes with metastatic disease in breast cancer upstages the patient and carries a poorer prognosis. It is the most important prognostic factor after axillary nodal status. Although 75% of the breast lymphatic drainage goes to the axillary lymph nodes, extra-axillary lymph node basins drain the remainder. Extra-axillary recurrences led to the evolution from Halsted’s radical mastectomy to Wangensteen’s “super-radical” and Urban’s “extended-radical” mastectomies, which remove the internal mammary and supra-clavicular lymph nodes in addition to axillary nodes. However, these surgeries failed to improve disease free survival and overall survival and the interest in pursuing extra-nodal metastasis faded away. With the development of the sentinel node techniques, interest in extra-axillary lymph node metastasis was renewed because of identification of drainage to these locations. Several reports from different institutions demonstrate this renewed interest as well as the feasibility of procedures leading to upstaging and changing of treatment plans when metastasis to internal mammary nodes is identified. In this review, the literature addressing internal mammary lymph nodes in breast cancer is examined. Methods : Systematic review of the literature from 1867 to 2015. Conclusion : The techniques and factors that affect the reliability and reproducibility of internal mammary sentinel node biopsy are discussed. In addition, we discuss whether the treatment of positive internal mammary nodes translates into a survival advantage. Finally, we propose a minimally invasive working algorithm to internal mammary lymph node evaluation.